A qualitative study of organisational resilience in care homes in Scotland

Providing care for the dependent older person is complex and there have been persistent concerns about care quality as well as a growing recognition of the need for systems approaches to improvement. The I-SCOPE (Improving Systems of Care for the Older person) project employed Resilient Healthcare (RHC) theory and the CARE (Concepts for Applying Resilience) Model to study how care organisations adapt to complexity in everyday work, with the aim of exploring how to support resilient performance. The project was an in-depth qualitative study across multiple sites over 24 months. There were: 68 hours of non-participant observation, shadowing care staff at work and starting broad before narrowing to observe care domains of interest; n = 33 recorded one-to-one interviews (32 care staff and one senior inspector); three focus groups (n = 19; two with inspectors and one multi-disciplinary group); and five round table discussions on emergent results at a final project workshop (n = 31). All interviews and discussion groups were recorded and transcribed verbatim. Resident and family interviews (n = 8) were facilitated through use of emotional touchpoints. Analysis using QSR NVivo 12.0 focused on a) capturing everyday work in terms of the interplay between demand and capacity, adaptations and intended and unintended outcomes and b) a higher-level thematic description (care planning and use of information; coordination of everyday care activity; providing person-centred care) which gives an overview of resilient performance and how it might be enhanced. This gives important new insight for improvement. Conclusions are that resilience can be supported through more efficient use of information, supporting flexible adaptation, coordination across care domains, design of the physical environment, and family involvement based on realistic conversations about quality of life.


Caring for older adults in care homes
Providing care for the dependent older person is vital and rewarding but presents many organisational challenges. Staff look after vulnerable residents with complex needs while balancing efficiency demands, resource constraints and policy and regulatory requirements [1]. Despite improvement efforts there have been persistent concerns about the quality of care in areas such as nutrition [2], oral care [3,4] pressure ulcers [5], and risks associated with polypharmacy [6] as well as a growing recognition of the need for holistic, person-centred care focused on quality of life [7].
Complex care and support needs underpinned by disability and comorbidity are placing increasing demands on staff [8] that have been exacerbated by the COVID-19 pandemic and response [9]. UK data suggest an over 200% rise in all-cause mortality in nursing homes [10] with dementia being the most common pre-existing condition for those whose death was recorded as COVID-19 [11]. In Scotland, around a third of COVID-19 deaths have occurred in care homes [12], and larger homes were more at risk [13].
The historical separation of health and social care has had detrimental effects on the staffing and funding of social care [14]. Programmes to improve safety and quality, which are now relatively mature in acute settings, are not implemented to the same extent in the social care sector, where important distinctions are made between home and institution, and between residents and patients [15]. Improvement efforts are primarily concerned with increasing staff knowledge, awareness and skills though education and/or training [16,17]. However, in complex care settings, interventions that do not consider broad system interactions between organisational processes and tasks, design and technology, and patient needs "are unlikely to have significant, sustainable impact" on safety and quality [18].
Across the wider healthcare landscape, the use of organisational theory and tools is endorsed [19] and the need to study healthcare as a complex system prior to designing and implementing improvement efforts has recently been formally recognised [20]. Traditional improvement strategies focus on identifying problems, for example from complaints, incident reports or inspection reports, and targeting their reduction. This retroactive, deficit-based endeavour has been termed the 'find and fix' approach [21] and its limitations have led to the complementary study of how success is achieved under difficult conditions as a basis for identifying improvements [22].
To address this gap in the application of healthcare systems theory to care home improvement, the aim of the I-SCOPE (Improving Systems of Care for the Older person) project was to systematically examine how care home systems deliver care, with a focus on how staff achieve positive outcomes by balancing multiple competing priorities in the context of dynamic conditions, to inform improvement efforts.

Resilient healthcare
I-SCOPE utilised the systems-theoretical model of Resilient Healthcare (RHC). The international RHC literature presents an innovative set of ideas about how safe, quality care emerges and can be enhanced by focusing on how to support organisations in achieving outcomes which emerge from complexity in everyday work [23]. The idea of 'resilience' in RHC is concerned with "the capacity to adapt to challenges and changes at different system levels, to maintain high quality care" [24].
We applied the CARE (Concepts for Applying Resilience Engineering) model [25,26] which drove the research questions, observation guides, interview schedules and data analysis.
The model was developed to guide in depth fieldwork to identify organisational resilience and how it might be increased [26]. It is a generalised abstraction identifying the key theoretical concepts and the relationships between them so that they might be investigated empirically. Specifically, the model presupposes that full alignment between work demands and organisational capacity is rarely achieved, thus the care system has to dynamically adapt and adjust to achieve its aims. The distinction is thus made between what is intended or ideal ('work-as-imagined') and the actuality of everyday work ('work-as-done'). To understand work as it is done in practice there is a need to study how dynamic adaptations occur. The CARE model has been applied in various hospital settings and has been extended to include factors that stimulate adaptation, and processes through which adaptations occur [27,28].
This theory-based approach is intended to be used to describe everyday work, which then allows for the identification of improvement opportunities. This is approached through a conceptual lens that examines five key organisational activities or potentials which support this everyday work, that is which are needed for a work system to function in a resilient manner: anticipating issues that may arise; responding to conditions and indicators; monitoring the system e.g. in terms of needs or outcomes; and learning from experience, e.g. what worked well and what could be done differently; coordinating tasks and resources [29,30].

Aims
The overarching aims were: a) to systematically study and describe how everyday care is delivered and how staff adjust and adapt to achieve successful outcomes; b) to identify general areas for informing potential improvement in organisational resilience.

Methodology
A qualitative methodology was chosen as most appropriate to meet the aim of describing how everyday work is performed and how staff, teams and organisations adapt to complex conditions and demands.

Recruitment
Care Homes were recruited under principles of theoretical sampling [31]. A frame was built to ensure a spread across: type of provider; size of home; size of provider; geographical Health Board; residential or residential plus nursing homes. The ENRICH (Enabling Research in Care Homes) network, the Care Inspectorate and Scottish Care assisted with distribution of recruitment material by email outlining the aims of the research team.
All individual participants (staff in homes, focus groups, and workshop participants) were purposively recruited and formed a non-probabilistic sample to ensure sufficient spread to inform the study [32].

Procedures
Observations, staff interviews, Focus Groups and round  [33] was drawn up to capture: time and place; descriptions of activities; people and materials involved; goals and reflections; emerging questions and potential areas for future study. Staff were asked questions discretely where possible. Subsequent observations were more focused and selective (see Table 1) based on emerging themes from initial shadowing of staff, and liaison group input on priority areas of care.
Staff interviews. Through discussion with managers, carers and senior carers were recruited purposively to inform the aims of the research and to ensure a range of perspectives were gathered. All staff interviews took place one-to-one in care homes using private rooms. Interviews were piloted with two care home managers; these were included in analysis with consent. This involved broad questions to start, then targeted questions and prompts with regards to personal care, medication, mobility/ falls risk, nutrition/ weight management, oral care, and social activity. This structured approach did not preclude the emergence of data themes which apply across all these areas, such as frailty and end of life care, dementia care, holistic outcomes such as quality of life, and general functions such as managing staff, care planning and administration.
Focus groups. Three Focus Group discussions were held in central locations with travel remunerated: two with staff from the Care Inspectorate including Team Managers and Senior Improvement advisors (recruitment facilitated by HE); one with a multi-disciplinary group from liaison teams providing a focus for multi-disciplinary working across homes (recruitment purposive facilitated by care home staff).
Resident and family interviews. In initial discussions, our advisory group suggested that involving residents might be best approached by briefing care home staff to conduct short interviews. It was felt this would be less invasive and have less potential for distress than if residents were approached directly by members of the research team.
We collaborated with My Home Life (MHL) to recruit residents and family members and to gain expert advice on conducting the interviews. MHL is an international initiative that aims to promote quality of life for those living, dying, visiting and working in care homes. It is underpinned by relationship centred care [34], Appreciative Inquiry [35] and Caring Conversations [36] with a focus on developing best practice collaboratively. After ethical amendment to allow the involvement of care home staff in fieldwork, we held a collaborative briefing event with staff already exploring care by engaging with residents through their participation in the MHL Leadership Support and Community Development programme [37]. We designed resident and family member interviews/dyads to be carried out by staff using 'emotional touchpoints' [38], an approach to interviewing that enabled us to explore experiences relevant to our research in a structured way focused on emotions. The briefing allowed us to outline our research questions and aims and ensure they could be explored using this modality. Organisational principles from the new Health and Social Care Standards [39] were used as a guide to elements of daily care that were then introduced in a neutral manner. These principles outline care expectations e.g. "I have confidence in the organisation providing my care and support". Participants were asked to select from a range of words (for example: comfortable; encouraged) that summed up how they experienced these, and prompted to explain why. This approach was selected as it can enable individuals to describe feelings in a way that makes sense to them and captures aspects of care that can be hard to define and/or incorporate in standard interview schedules [40].
Project workshop and round table discussions. A final project Workshop was held, also in a central location. This brought together researchers, care home participants and wider professional stakeholders (including those from policy, regulatory inspection, medical, nursing, dental, pharmacy, nutrition and psychology backgrounds) to discuss findings and recommendations. We chose the method to work dually as an engagement event to maximise impact of the research and as a chance to conduct further in-depth discussions focused on the main emergent findings/ themes. Recruitment as above was purposive through contacts at Scottish Care, the project liaison group (care home managers) and the advisory group. After talks from project researchers and managers and carers reflecting on the work, five round table discussion groups were facilitated and recorded. Topics were chosen based on thematic findings from the fieldwork. Excerpts (either direct quotes or notes from observation) were presented as prompts for separate discussions on oral health; medication; social activity; diet and nutrition, and falls/ mobility. Participants were told these were initial themes rather than definitive findings, in order to generate reflection and debate. Then all five groups were given prompts for a more general discussion on the emergent themes in terms of organisational resilience, and again asked to give their opinions and reflect on any implications. Analysis QSR NVivo 12.0 was used to manage transcripts, notes, images and care documents. All interview, Focus Group and Workshop Round Table discussions were digitally recorded and transcribed verbatim. Audio recordings and photographic images were frequently used to supplement observations and facilitate note taking. Interview notes were also taken and collated. In addition, interviews with staff often involved discussions of care documents and artefacts such as care plans and notes, electronic monitoring systems, resident charts, inspection documents, and protocols and guidance. The number of interviews and focus groups was finalised based on principles of data saturation, where no new themes were deemed to be emerging from analysis [41].
A two-stage analysis was carried out in line with RHC methods and guidelines for applying the CARE model. This theory-based approach is relatively deductive, in that RHC provides a frame within which to describe everyday work and examines this with a focus on resilient performance (or otherwise). Two experienced coders of RHC data and the main project researcher (AR, JA, SS) analysed and coded excerpts using the CARE model concepts and the underpinning resilience activities [42]: • Capturing work-as-done. First, contextual examples from different areas of care were extracted, describing everyday work or 'work-as-done' in terms of the interplay between demand and capacity, adaptations (e.g. trade-offs and priority decisions), and intended and unintended outcomes. This gives a rich description of how outcomes emerge from the interplay between complex system conditions and dynamic adaptation/ adjustment (Table 2).
• Describing resilience in everyday work. The next step was to synthesise data from step 1 into a higher-level thematic description which gives an overview of resilient performance. This involves examining the breadth of 'everyday work' ( Table 2) to identify where the five resilience activities are indicated as supportive (or not), that is: where the work system more generally is functioning in a resilient manner or otherwise and thus where attention for intervention can be focused. Table 3 shows three main themes that emerge from this stage of analysis. These cut across the different domains of care and thus characterise organisational resilience whereby "the output from this step should be a comprehensive overview or map of the resilience in the system" [29].
Coded excerpts describing work as done and resilience themes were put forward as propositions and tested during round table discussions with stakeholders at the project workshop (see Table 1). Stakeholders reviewed the analytic propositions and provided recorded comments and feedback which validated them as reflective of their own experiences and opinions on the characteristics of the work system.

Reflexivity
The team involved registered nursing staff as well as psychologists and four qualified ergonomists. However, the principal research associate at the time was medically trained which may have influenced her observational note taking and aspects disclosed by staff. Residents were engaged by staff who knew them well. We believe this was the best course of action but prior assumption and experience may influence data gathered.

Project oversight, ethical approval and consent to participate
An external scientific advisory group gave input at an early stage and a project liaison group was formed with managers of case study homes (there were no existing relationships between researchers and participants). Ethical advice was sought from the local NHS Research Ethics  Service and the officer with special responsibility for adults with incapacity, who advised that under the terms of the governance arrangements for research ethics committees in the United Kingdom, NHS ethical review was not required and university approval would suffice. NHS approval was ultimately deemed unnecessary and thus the study was approved in writing by the University of Glasgow (College of Medical Veterinary and Life Sciences) Institutional Review Board (Project Ref: 200150178). Reporting follows COREQ guidelines [43]. All interview and Focus Group participants gave fully informed, written consent. Table 1 shows data sources. It can be seen from Table 1 that there were 68 hours of observation during daily delivery of care, n = 33 one-to-one recorded interviews, and n = 50 respondents took part in Focus Group discussions.

Capturing work-as-done
Everyday care for residents is characterised by staff adapting and adjusting to multiple dynamic demand and capacity issues to achieve positive outcomes. Table 2 shows illustrative examples, giving an indication of how this is widely manifest and characterises organisational activity across various domains of care. Table 2 shows a complex care landscape. Residents' needs fluctuate over time and are hugely variable in terms of frailty, cognitive capacity, personal choice, family involvement and other factors. Demand on the system, including in residential as well as nursing homes, is increasing and there are constant dynamic changes to conditions and variable interacting issues to deal with. Staffing can be an issue and time to provide care in line with residents' needs and preferences is at a premium. All areas of care are supported by staff and organisations being flexible and adapting to circumstance.

Describing resilience in everyday work
The next step in analysis was to induce higher level resilience themes which apply across the domains of care in Table 2 and are described below: Care planning and use of information; Coordination of everyday care activity; Providing person-centred care. Table 3 contains further illustrative quotations, with short descriptions of how the key resilience activities (anticipating, responding, monitoring, learning and coordinating) are observed to be present, or to have room for improvement, under each of the three theme Theme 1: Care planning and use of information. Information flow (verbal and non-verbal) is key to care monitoring and learning about what is working. Care plans and incorporated risk assessments work best when they are adaptable and used flexibly: However, monitoring can often be prone to inefficiency, which increases demand and erodes response capability. Documents can be seen by carers as primarily an administrative requirement and the ability/ motivation of care staff to document care through written process is highly variable. Managers share learning on care plans but documentation often proliferates in an ad hoc fashion and don't seem clearly focused, increasing demand on staff and impacting directly on time spent with residents.
Some 'streamlining' of tools so that they are efficient monitoring and anticipatory tools is felt to be beneficial. In general, there are positive orientations towards electronic care monitoring and planning systems and their potential to reduce demand and improve 'real time' monitoring and anticipating. Finally, planning care and responding to need can be constrained by capacity in the built environment. Aspects such as stairs, gardens, size and function of units (e.g. palliative units) provide the context whereby care is carried out and again this requires staff to consider priorities, monitor and anticipate risk, and make adaptive decisions on an ongoing basis (Table 3).
Theme 2: Coordination of everyday care activity. Successfully caring for multiple residents with complex needs does not arise from simply following protocol, but from flexible responding. Success requires constant priority judgements, underpinned by coordination, anticipation, and response to emergent issues: [Senior Social Care Worker Home 5, interview] Importantly, learning in this vital area is described as happening mainly through experience rather than through formal reviews or educational efforts. Local management/organisational culture is key to developing staff skills in prioritisation decisions and coordination of tasks and activities. At an organisational level, liaison teams facilitate coordinated care by bringing together different services and specialties. what the staff are actually doing to make that person's life better. It may be the slightest thing, but the staff don't get the opportunity to do that sometimes. Every moment counts for a resident, that's for sure, but it's how that's achieved, and sometimes there's not enough staff to do the little things, the little quirks that the individual likes, listening to hymns or whatever; that or getting taken to the café somewhere one day a week or whatever-there's just not sometimes the staff to be able to do that.
[Care Home Manager, multi-disciplinary Focus Group discussion] Care planning and monitoring can still be somewhat compartmentalised into different domains. Resident and family input is vital, but family expectations can be unrealistic. As above in terms of coordination, care liaison teams that provide a platform for integrated services are discussed in positive terms (Table 3).
Assessment, inspection and evaluation need to be based firmly on realistic expectations of care outcomes and processes. In terms of monitoring outcomes, there is some concern about how to provide clear evidence for outcomes based on overall quality-of-life when it comes to inspection. Providers need to liaise with regulators and commissioners to align their own internal quality measures with external ones. Good inspection is described as being similarly holistic in focus, rather than focused on documentation of processes per se (see Table 3).

Main findings and recommendations
This study aimed to examine complex work conditions in Care Homes. An in-depth qualitative study across multiple sites was conducted over 24 months drawing from ethnographic principles which are common in the RHC field [44] due to the need to gain a rich understanding of everyday work [45]. The study generated a comprehensive description of the care home system viewed through resilient health care theory.
The ability of staff, teams and organisations to adapt and adjust to anticipated and unanticipated variation is vital for sustaining operations and achieving good outcomes.
Together, the descriptions of work as done and themed resilience indicators begin to show how safe, high quality care is created in the context of complex interactions between people and aspects of the socio-technical environment such as the built environment, leadership, and the management of external pressures [46].
Staff adapt to dynamic, variable conditions and coordinate and make priority decisions based on experience in the job. There are restrictions and difficulties in terms of the physical environment and the burden of paperwork for information gathering, monitoring and responding. Care is still relatively fragmented at times but there are concerted efforts to focus holistically on residents' preferences and quality of life.
Managers and staff on the whole support good outcomes through adapting and adjusting to variable resident needs, environmental conditions and everyday events. There have been calls for investment in the front-line carer workforce, including strengthening training requirements and opportunities, and creating advanced roles [47]. But training can only be part of the approach. System resilience is underpinned not just via care skills and knowledge garnered through training and guidelines, but by non-technical skills (communication, coordination, decision making), making best use of design and physical infrastructure, and by experiential or 'tacit' knowledge that is substantially learned 'on the job'. There is little training provided for key coordination activities, such as prioritising tasks, anticipating, responding to interruptions, and synthesising conflicting information, which are shown to be vital in everyday care delivery.
Paperwork generally acts as a barrier to care, as previously reported [48]. The move to electronic systems in many care homes could lead to more timely and efficient recording of information, and better care through monitoring and the sharing of accurate information. However, the benefits (and potential negative consequences) of this move warrant further investigation with all relevant stakeholders. Attention is turning in recent years towards organizational-level approaches to implementation and improvement [49]. Interventions must be based on models of healthcare systems and theories of how people, tools and resources interact if they are to be consistently effective [50,51].
Interventions need to support providers' ability to adapt and adjust as they meet the challenges of providing safe, high-quality care for older people. These can be targeted either at reducing misalignments, supporting the potential for organisational resilience, or both, but must be based on studying 'work-as-done'. The complex and varying needs and preferences of residents means that care homes are dynamic environments that pose many difficult priority decisions for the people working in them (advanced dementia care was described by one inspector as 'fiendishly difficult'). Focusing on care omissions can be important [52] but this needs to be complemented by identifying and supporting flexible local pathways to success.

Summary of findings and recommendations
• Work conditions in care homes are inherently dynamic and this needs to be considered a complex, specialised area of care.
• Flexible use of staff, physical space and documentation, based on local conditions, should be supported where a valid case can be made for their effectiveness and where they are based on structured thinking about risks and benefits, involving multiple perspectives.
• Care plans should be simplified and duplication of information removed. Family input is vital. Training on how to produce care plans should be strengthened. Electronic solutions for care monitoring and planning have the potential to improve care via sharing of more complete, accurate and timely information in an efficient way; potential benefits and unintended consequences both need further investigation.
• Task prioritization and mindful adaptation to variable conditions and multiple goals should form part of training. Currently this is tacit knowledge, learned through 'trial and error' on the job. Such training might take the form of simulated practice situations or vignettes that mimic real-life scenarios and allow staff to safely work through and discuss them, as is common in hospital care [53].
• Functions such as local care home liaison groups which support multi-disciplinary input (nutritional, psychological, social, medical and dental, physiological etc) to care plans and assessments are recommended.
• Organisational considerations must be incorporated into the design of guidance and implementation efforts, even for seemingly simple activities. We reported ( Table 2) how staff feel the physical design and layout of homes affects planning and responding to need. Some level of basic task analysis for key activities involving staff, residents and families is recommended to find the optimal way to achieve good care in the given built environment, and/or how redesign might help.
• As well as assessing care provision holistically there is a need for formal recognition that all risk cannot be eliminated with a vulnerable population, finite resources, and a goal to maintain independence and mobility; inspection should focus on quality of life and risk being as low as reasonably practicable [54].

Strengths and limitations
Organisational factors are frequently cited as important in care practice [55], yet organizational theories themselves are under-utilized in supporting routine delivery of care. [56,57] The I-SCOPE study applied such theory to the care home setting in a systematic way using a model of Resilient Healthcare, undertaking extensive multi-modality fieldwork across a range of settings and fully involving a wide range of stakeholders. A further strength was the inclusion of residents and family members under principles of process consent [58] after ethical amendment. Residents with dementia are excluded from providing insight and perspective in many studies due to traditional ethical/ consent requirements. Staff were able to engage this vulnerable group, helping residents to share their experiences in a structured but non-threatening way. This paper reports on qualitative research based on rich description of a small number of self-selecting participant sites where people were motivated to take part. The findings were validated at Workshops with other stakeholders and are worthy of further validation efforts on a wider scale. The study took place prior to the major disruption of the COVID-19 pandemic and a number of changes to everyday work have since been observed. However more recent studies have shown that there is an ongoing need to make difficult trade-off decisions and co-ordinate dynamic responses to local conditions (e.g. Marshall et al. stress the importance of 'the ability of care home staff to identify and solve emerging issues in care homes' [59]). There is also recognition of the importance of organisational and workforce management strategies, as well as known drivers such as staffing ratios and access to critical resources [60].

Conclusions
This study has made recommendations to support the ability of staff, teams and organisations to adapt and adjust to anticipated and unanticipated variation which is vital for sustaining operations and achieving good outcomes. Everyday work in the care home sector is complex and pressured. Systems approaches are vital, and improvement should prioritise design and configuration of work system elements thus 'making it easy to do the right thing'; there are opportunities for providers and inspectors working together to support adaptive capacity, (through for example task analysis, simulated practice, and design of spaces and work procedures based on ergonomic principles) supporting how to do things under variable conditions, rather than simply telling people what to do based on ideal circumstance [61][62][63].
The need for good organisational science applied to care home improvement has arguably never been greater. There is now a wealth of literature [64,65] on the difficulty of intervening successfully in healthcare systems, which are complex [66] and involve dynamic interacting components [67]. We understand the notable challenge of finding accessible applications of organisational theory to understand systems into which interventions are designed [68]. Employing such methods is however important for sustainable change [69]. Finally, when seeking to design or implement interventions, realistic models of consent should be explored to include as many residents as possible in giving perspectives on and co-designing care.
Supporting information S1 File. Consolidated criteria for reporting qualitative studies (COREQ) checklist. (DOC)